Basic Information
| Provider Information | |||||||||
| NPI: | 1396199824 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SEATTLE EXTRACORPOREAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | VIRGINIA MASON MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4446 88TH AVE SE | ||||||||
| Address2: | |||||||||
| City: | MERCER ISLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980404148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2069399898 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 925 SENECA STREET | ||||||||
| Address2: | SEATTLE EXTRACORPOREAL | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062236600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2016 | ||||||||
| LastUpdateDate: | 04/21/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | RAY | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL PERFUSIONIST | ||||||||
| AuthorizedOfficialTelephone: | 2069399898 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NO | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CCP | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 819241 | WA | Y | Hospitals | General Acute Care Hospital | Critical Access |
No ID Information.